Keywords
laparoscopic - appendectomy - appendicitis - acute - recurrent
Acute appendicitis is the most common cause of acute abdomen in almost all age groups.[1]
[2] Ever since Charles McBurney described traditional appendectomy in 1894 for acute
appendicitis, open appendectomy (OA) flourished as gold standard treatment for appendicitis.[3] OA was considered safe, effective, and standard modality of treatment in appendicitis
for almost a century. Though easy to perform, OA had a plethora of drawbacks due to
variability in the inflammatory process and position of appendix, increased postoperative
pain, prolonged hospital stays, delayed return to normal activities, wound- and scar-related
complications, and inability to visualize the concomitant pathologies. With the advent
of minimally invasive surgery (MIS), laparoscopic cholecystectomy gained immense popularity
for the management of symptomatic gallstone disease; however, it was not the same
case with laparoscopic appendectomy (LA).
Semm, a German gynecologist, performed the first LA in 1984.[4] With advancing MIS, the incidence of LA has increased in the past decade. LA offered
lesser postoperative morbidity, early recovery, opportunity to perform a diagnostic
laparoscopy, and cosmetically better scars than OA.[5]
[6] Though rapidly advancing surgical practice is more inclined toward MIS, the drawbacks
associated with LA such as prolonged intraoperative duration, steep learning curve,
higher incidence of intraabdominal abscess, and cost-ineffectiveness cannot be ignored.
The relative pros and cons of OA and LA in the management of appendicitis have been
debated and compared by numerous randomized controlled trials in the past; however,
the dilemma in choosing a single best procedure in a clinical scenario is still lingering.[7]
This prospective comparative study describes our experience and compares various primary
outcome measures in the management of acute and recurrent appendicitis by OA and LA
in a tertiary care hospital.
Materials and Methods
This single-center prospective comparative study was conducted in the General Surgical
Units of JJ Hospital in Mumbai, India, between June 2015 and October 2019. The objective
of the study was to compare various intraoperative and postoperative factors influencing
the management of acute and recurrent appendicitis by OA and LA. Primary outcome measures
such as intraoperative duration, postoperative pain, length of postoperative hospital
stay, time for returning to normal activity, postoperative complications, rate of
conversion, and subjective cosmesis were the parameters considered for comparison.
A total of 60 patients presenting to the surgical outpatient department with right
lower quadrant pain were included in the study after obtaining informed consents from
the subjects and a clearance from the Hospital Ethical Committee. Diagnosis was made
after a thorough clinical examination, Alvarado MANTRELS scoring (score> 7), and/or
ultrasound/contrast-enhanced computed tomography (CT) scan evidence of an inflamed
appendix. The inclusion and exclusion criteria for the study were as follows:
Inclusion Criteria
-
Patients presenting with right iliac fossa pain with diagnosis of acute and recurrent
appendicitis after clinical exam, MANTRELS score (>7) and USG/CT scan.
-
Patients between the age of 12 and 70 years.
-
Nonpregnant patients.
-
Patients of American Society of Anesthesiologists (ASA) class 1 and 2.
-
Patients consenting for the procedure and ready to abide by the follow-up protocols.
Exclusion Criteria
-
Patients below 12 years and above 70 years of age.
-
Cases with chronic appendicitis, phlegmon, and appendicular abscess.
-
Subjects not fit after preanesthetic check and ASA class ≥3.
-
Pregnant patients.
-
Subjects not willing to consent for the procedure and not feasible with regular follow-up.
Subjects were divided into two groups by lottery method into the ones undergoing LA
and OA to avoid selection bias. Patients were admitted on the day of surgery; routine
laboratory, and radiological tests including complete cell counts, liver and renal
function tests, hepatitis B, C, and HIV screening, chest and abdominal radiographs,
electrocardiogram, and ultrasonography of the abdomen and pelvis were performed. Patients
were explained about the risks and benefits of both the procedures and written informed
consents were obtained. Surgeries were performed in same operating room complex by
five different surgeons with adequate similar skills in both open and laparoscopic
surgeries. All patients received a dose of third-generation cephalosporin intravenous
antibiotic at the time of induction.
OA was performed under spinal anesthesia with traditional Lanz incision. Muscles were
spilt, peritoneum incised, appendix was mobilized, and mesoappendix was ligated with
polyglactin 2–0 sutures and divided. Appendix was then crushed, transfixed, ligated
at the base with polyglactin 2–0 and divided. Skin was closed with simple sutures
using Nylon 3–0. LA was performed with conventional three-port technique. Umbilical
port (10 mm) was inserted and pneumoperitoneum was created by open approach, followed
by 5 mm ports in the suprapubic region and the left iliac fossa under vision. Mesoappendix
was sealed using bipolar electrosurgical device and divided. Appendix was doubly ligated
at the base with Roeder's knot using chromic catgut and was divided and retrieved
in an endobag through the 10 mm port site. Skin was closed with simple sutures using
Nylon 3–0. Lavages were given in two cases of OA and one case of LA. Drains were not
inserted in any LA or OA case. Appendicitis was confirmed after histopathological
examination of all the samples. Patients were started on oral liquids on postoperative
day 1 and day 2, respectively, in LA and OA patients. Soft diet was started once oral
liquids were tolerated well ([Figs. 1]
[2]
[3]).
Fig. 1 Port position in laparoscopic appendectomy.
Fig. 2 Appendix doubly ligated with laparoscopic Roeder's knot.
Fig. 3 Appendicular stump after division.
Various intraoperative and postoperative parameters were recorded and analyzed. Intraoperative
duration (in minutes), which was defined as the time from skin incision to the last
stitch of skin closure in OA and from infraumbilical port insertion to closure of
the last defect in LA, was recorded in all cases. Intraoperative complications such
as hemorrhage, visceral injuries, and conversion to open surgery were recorded. Postoperative
complications such as hemorrhage, wound discharge, wound gape, and intraabdominal
abscess were looked for. Postoperative pain was assessed on 1st, 2nd, and 7th postoperative
days using visual analogue scale (VAS). Length of postoperative stay defined as the
number of nights spent in the hospital after surgery was noted in all cases. Time
for returning to normal activities was defined as the time taken after surgery (in
days) when abdominal discomfort did not interfere with normal daily activities. The
final cosmesis in both LA and OA, as perceived by the patient using the Scar Scale
on a scale of 3 to 15, with 3 being the best result and 15 being the worst, was recorded
on 30th postoperative day. Patients were followed up at the end of 1st, 2nd, and 4th
weeks after the surgery. Sutures were removed at the end of 1st postoperative week
in all cases.
Results
Total of 60 patients were included in the study. All patients undergoing appendectomy
for acute and recurrent appendicitis were explained about the merits and demerits
of OA and LA. Continuous variables such as age, operative duration, length of hospital
stay, VAS score, and time to return to normal activity were expressed as mean ± standard
deviation and categorical variables such as gender, conversion rates, and postoperative
complications were expressed as percentages. Details were entered into the Statistical
Package for the Social Sciences (SPSS) software for statistical analysis of the data.
Mann–Whitney U test was used to compare continuous variables and chi-squared test
was used to compare categorical variables. p-Value≤0.001 was considered to be statistically significant.
Out of 60 patients, 30 underwent OA and 30 underwent LA. Both the groups were comparable
in their clinicopathological parameters and all efforts were made to avoid confounding
factors. No mortality, readmission, or re exploration was encountered in either group.
The median age of patients undergoing OA and LA was 24.9 and 25.2 years, respectively.
p-Value was 0.221, indicating no statistically significant difference between the two
groups with respect to age. The number of females in both groups was higher in comparison
to males with female: male ratio of 1.30 in OA and 1.14 in LA, respectively. p-Value of 0.795 indicated no statistically significant difference between the two
groups with respect to gender. About 33.33% of LA were performed in acute appendicitis,
66.67% of LA were performed in recurrent appendicitis. Similarly, 30% of OA were performed
in acute appendicitis, and 70% in recurrent appendicitis. p-Value >0.001 indicated no significant statistical difference.
The mean operative duration in LA and OA group was 47.17 ± 14.39 minutes and 36.9 ± 12.33
minute, respectively, with p = 0.001, indicating a statistically significant difference between the two groups
with respect to operative times. This difference was attributable to the steep learning
curve of laparoscopic procedure as no intraoperative complications were encountered
in any of the LA prolonging the operative duration. The median VAS score in LA and
OA group was 3.5 and 5, respectively, with p = 0.001, indicating significant statistical difference with respect to postoperative
pain between the groups. The mean length of postoperative stay was 3.69 ± 0.71 days
in LA group and 5.28 ± 0.63 days in OA group with a p = 0.000, indicating a significant statistical difference. The mean time to return
to normal activity in LA group was 8.13 ± 1.33 days and that of OA group was 10.10 ± 2.20
days with p = 0.000, indicating a significant statistical difference. There were no conversions
to open procedure in the LA group. No concomitant pathological findings were seen
in both groups. Two cases (6.66%) in LA group and 4(13.33%) in OA group developed
fever and serous discharge from the wound on the 2nd postoperative day, p = 0.652, indicating no significant statistical difference between the two groups
with respect to postoperative wound-related complications. The mean scar scale scoring
done on 30th postoperative day was 4.23 in LA and 8.23 in OA with p = 0.000, which suggested significantly better scars after LA in comparison to OA
after 1 month of postoperative period ([Fig. 4] and [Table 1]).
Table 1
Demographic details and primary outcome measures
|
Parameter and outcome measures
|
LA
(n = 30)
|
OA
(n = 30)
|
p-Value
|
|
Median age (y)
|
25.2
|
24.9
|
0.221
|
|
Gender
|
Males—13 (43.3%)
|
Males—14 (46.7%)
|
|
|
Females—17 (56.7%)
|
Females—16 (53.3%)
|
|
Female:male
|
1.14
|
1.30
|
0.795
|
|
Mean operative duration(min)
|
47.17 ± 14.39
|
36.9 ± 12.33
|
0.001
|
|
Median postoperative VAS score
|
3.5
|
5
|
0.001
|
|
Duration of postoperative hospital stays (d)
|
3.69 ± 0.71
|
5.28 ± 0.63
|
0.000
|
|
Mean time to return to normal activities (d)
|
8.13 ± 1.33
|
10.10 ± 2.20
|
0.000
|
|
Postoperative complications
-Wound infection and fever
|
6.66%
|
13.33%
|
0.652
|
|
Mean scar scale score on 30th day
|
4.23
|
8.23
|
0.000
|
Abbreviations: LA, laparoscopic appendectomy; OA, open appendectomy; VAS, visual analogue
scale.
Fig. 4 Graphs comparing mean operative duration and hospital stays in laparoscopic appendectomy
(LA) and open appendectomy (OA). OT, operation theater.
Discussion
“Appendix: forgettable, yet not so forgotten”
This underdeveloped residuum of the cecum has no known function and is commonly termed
as a “vestigial” organ, yet diseases of the appendix loom large in surgical practice;
and appendicitis continues to be the most common acute abdominal condition that requires
immediate surgical treatment.[4]
[8] Early and prompt treatment will help in prevention of complications such as perforation,
lump, and abscess formation. Though appendicitis presents with typical pain in the
umbilical region at clinical presentation, which further localizes to right iliac
fossa in 50 to 60% population, conditions such as ovarian cysts, ectopic pregnancy,
pelvic inflammatory disease, and ileocecal Koch's are not uncommon differentials.[9] However, no evidence of negative appendectomies or misdiagnoses was found in our
study. Both the groups in our study were comparable in terms of gender and ages of
the patients with no significant statistical differences.
Consideration of operative duration in comparison of LA and OA has always been of
importance in literature. The mean operative duration in OA was lesser than in LA
in our study, which was statistically significant. This was in coherence with the
studies by Yong et al with median operative duration being 80 minutes in LA and 60 minutes
in OA groups and by Rashid et al with mean operative duration of 33.9 ± 78 minutes
in OA group and 57.64 ± 9.89 minutes in LA group.[10]
[11] This was attributed to steeper learning curve of laparoscopic surgery. The median
operative duration decreased with improving surgical skills of the surgeon over time
in many studies. Both OA and LA were performed by a group of five surgeons in our
study with adequate skills. However, as per the study by Khalil et al, the prolonged
durations in LA can be attributed to additional maneuvers in LA such as creation of
pneumoperitoneum, trocar insertion, and performing diagnostic laparoscopy that are
absent in OA.[12] The mean duration of hospital stay in our study was 3.69 ± 0.71 days in LA group
and 5.28 ± 0.63 days in OA group that was in corroboration to studies by Frazee RC
et al, Malik et al, and Mulita et al.[13]
[14]
[15] Patients undergoing OA experienced more pain compared with the LA group that prolonged
their recovery times and the duration of hospital stays. However, a study by Milewczyk
et al showed no significant difference in postoperative hospital stays in LA group
compared with the OA group.[16] Many authors have attributed the difference in postoperative hospital stays to the
healthcare system rather than type of the procedure.[17] Kurtz and Heimann stated that the duration of hospital stay was determined by the
appendiceal pathology rather than the type of procedure performed.[18] Patients with higher degrees of appendiceal inflammation were found to require longer
hospital stays. Mean VAS scores in LA group were less than OA group. Increased pain
in OA group was attributable to the length of fascial incision and stretch on the
wound compared with the LA group as per a study by Kim et al.[19] A study by Rashid et al reflected similar findings with mean VAS score of 5.14 ± 0.132
in LA group and 6.01 ± 0.118 in the OA group.[11]
Kehagias et al reported increased incidences of postoperative wound infections in
OA group compared with LA group.[20] This was attributed to the delivery of infected appendix through the abdominal incision
that increased the risk of infection. Safe delivery of the appendix in endobags is
considered to reduce the chances of postoperative infection rates as stated by Aziz
et al.[21] Surprisingly, the incidence of intraabdominal abscesses was found to be higher in
LA group by Tang et al, that was attributed to the increased diffusion of infection
due to high pressure in laparoscopy.[22] However, no statistically significant difference was seen in our study with respect
to postoperative wound infections, which was also a finding in a study by Guller et
al.[23] Return to normal activity depends on the country's culture and reimbursement systems.[24] However, the time taken after surgery in days when abdominal discomfort did not
interfere with normal daily activities was considered in this study, which was significantly
less in LA group. The patients in OA group took more time to return back to normal
activities due to significant postoperative pain. Scar scale scoring performed at
the 30th postoperative day revealed better scars in the LA group compared with the
OA group pertaining to the length of the incisions. Multiple factors such as cost-effectiveness,
stump appendicitis, and chronic complications were out of the scope of our study ([Table 2]).
Table 2
Comparing the various parameters of different studies with the current study
|
Parameter →
|
Operative duration (min)
|
Postoperative VAS score
|
Duration of postoperative hospital stays (d)
|
Time to return to normal activities (d)
|
Postoperative complications
|
|
Study ↓
|
LA
|
OA
|
LA
|
OA
|
LA
|
OA
|
LA
|
OA
|
LA
|
OA
|
|
Current study
|
47.17 ± 14.39
|
36.9 ± 12.33
|
3.5
|
5
|
3.69 ± 0.71
|
5.28 ± 0.63
|
8.13 ± 1.33
|
10.10 ± 2.20
|
6.66%
|
13.33%
|
|
Yong et al[10]
|
80
|
60
|
–
|
–
|
2
|
3
|
–
|
–
|
13.4%
|
15.1%
|
|
Rashid et al[11]
|
57.64 ± 9.89
|
33.9 ± 78
|
5.14 ± 0.132
|
6.01 ± 0.118
|
1.06 ± 0.2399
|
3.1 ± 0.8864
|
3.6 ± 1.03
|
9.64 ± 2.078
|
2%
|
2%
|
|
Frazee et al[13]
|
87
|
65
|
–
|
–
|
–
|
–
|
14
|
25
|
–
|
–
|
|
Milewczyk et al[16]
|
47.75
|
36.99
|
2.79
|
4.77
|
4.71
|
5.03
|
15.85
|
19.65
|
6.7%
|
9.4%
|
|
Kehagias I et al[20]
|
44.3 ± 24
|
47 ± 19.7
|
–
|
–
|
–
|
–
|
–
|
–
|
8.1%
|
10.6%
|
|
Mulita et al[15]
|
–
|
–
|
–
|
–
|
2.87
|
3.65
|
–
|
–
|
–
|
–
|
Abbreviations: LA, laparoscopic appendectomy; OA, open appendectomy; VAS, visual analogue
scale.
Conclusion
In conclusion, LA is more versatile approach than OA in the management of acute and
recurrent appendicitis. Prolonged intraoperative duration was the only drawback with
LA in our study; however, operative times were found to decrease with experience in
literature. LA offered lesser operative site pain in the postoperative period, shorter
postoperative hospital stays, leading to earlier recovery of the patient and return
to normal activities. Cosmetically, LA was found to give better scars to the patient
on a 30th day follow-up. Though wound-related complications were found to be higher
in OA in literature, no significant difference was seen in our study.
